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Aug31
JUVENILE DIABETES MELLITUS
Juvenile diabetes is one of the most common chronic conditions to affect children all over the world and each day, over 200 children are diagnosed with type 1 diabetes. Although Diabetes is a metabolic disorder, it can have psychosocial effect, if not handled in the right manner. As a long term condition that affects day-to-day living, diabetes can be particularly stressful on the child and parents. Newly detected Diabetes impacts all aspects of a child's life and its management requires the parents to tackle challenges at multiple levels physical, psychological, social and educational. If not effectively addressed, a spectrum of psychological issues ranging from lack of confidence to severe depression may result. However with proper training, learning about diabetes and making small changes in life style as a family, you can live a fairly normal life.As Diabetes affect all most organs of our Body ,it is decribed as Diabetes=flow or excess urine,(diuresis or called as POLYURIA),Mellitus= sweet as urine becomes sweet as sugar is excreted in it once our Blood Sugar level cross 180 mg% our kidney cannot absorb all sugar passing through it as sugar is lost person becomes weak(disabled) and need more food or hungry(POLYPHAGIA) and as with sugar more water or urine is also passed so person becomes more thirsty(POLYPEPSIA),these symptoms are very much seen in Juvenile Diabetes or young children then in Maturity Onset diabetes Mellitus (MODS) which affects mostly above 40 yrs of aged persons and mainly present with Metabolic Syndrome.Diabetes thickened intima of our Arteries because of Atherosclerosis as a result micro vessels or Arterioles becomes thickened and Hypertension develops which causes Kidney changes and chronic Renal Failure,Angina,Ischaemic Heart Disease,heart failure,Blocks etc,cerebro Vascular Accident, Ischaemia in Limbs,Ulcers and infections because of excess sugar in blood as well as inert and less responsive protective pain Nerve Fibres.Pain, Parasthesia,Numbness,Paresis due to radiculopathy are common in Diabetic patient,Ulcers and ischaemia of toes and fingers are serious because of single end arteries .patient also notice Sexual Dysfunction often not asked by doctor to patient and all these leads to depression and many psycho neurotic changes in patient and family members and parent leading to total social unjustment and belief in life leading to suicidal tendency due to despairness and loss of hope in life.

In this article, we examine the need for counseling and the various counseling options that a parent has to help a child and themselves deal with such issues.Becuase we belif that Diabetes is harmful but not invinsible,we can easily control it with modern medicines and change in life style with regular precautions and these children will live a normal life rather a better intelligent life ,only love,assurance and encouragement and help from parents and society is needed.
Counseling the diabetic child
A child diagnosed with diabetes is suddenly thrust into the unenviable position of dealing ith a chronic condition. Starting from dietary restrictions to insulin injections, the child has to come to terms with the all-pervasive impact of this condition. As a result, the child ay suffer from stress. Resentment, fear of being mocked at by peers, a fear of being branded as a 'sick' or 'ill' person, and anger at parental control on diet and activities are ome of the feelings that a child may experience. If allowed to build up, such feelings can have a debilitating effect on the child's mental and physiological health.
Parents can do a lot towards helping the child cope with diabetes. In fact, the attitude of parents plays a great role in forming the child's response to the condition. Paying enough attention to the psychological needs of the child can be as important as providing medication. By following these simple do's and don'ts, parents can empower the child as he/she work on responding to the condition.
Do not be over-protective. Many parents confuse precaution with apprehension and cross the fine line between being protective and over-protective. Understand that diabetes need not stop your child from leading a healthy, active life. Do not deter the child from participating in active sports and games in the mistaken belief that your child has to be protected.
2. Do listen and watch out for cues to your child's state of mind. Loss of appetite, sudden loss of interest in studies, reluctance to go to school, a listless attitude are some signs that your child needs help in coping with the condition.
3. Do not refer to the condition as a disease.It only helps to firm up an opinion that diabetes is to be feared and dreaded.
4. Do discuss the condition, its causes, treatment and precautions to be followed. An understanding about the physiological conditions and changes associated with diabetes will alleviate your child's fears about this condition and will equip him/her with the requisite knowledge to tackle it.
5. Do not express worries about the child's future, especially within earshot of the child.
6. Do not treat the child differently from his/ her siblings. This will only make your child more conscious about his/her condition.
7. Do take every opportunity to stress that diabetes is treatable.
8. Do focus on success stories of fellow diabetics from your child's area of interest - for example, successful cricketers, or athletes who are diabetics. Your child will profit from such role models.
9. Letting some one know about the fact that your child is diabetic should occur as naturally as divulging any other personal fact about yourself. If someone were to notice your child taking a shot and wondered what it was or why it was so, that would be a reason to explain! Don't express being diabetic as a negative thing or something that defines a person. Let it come naturally but definitely don't hide it. Be short, precise and positive while telling about it.
10. Be realistic in the goals set of your child.
11. Do set a personal example. Follow a healthy regimen of diet and exercise yourself to make it easy for your child to adhere to his.
12. Be understanding during the instance that your child deviates from the prescribed routine – your child is still a child and there may be occasions when he she feels the need to bypass the routine.

Counseling partners and caretakers
Juvenile diabetes impacts the entire family, not just the affected child. The parents of a diabetic child are also subject to stress, although for different reasons. In the case of parents, possible stressors are a fear of societal ridicule, apprehension about a girl child's marital prospects, worry about the child's longevity and future and sometimes guilt on not being able to protect the child from this condition. Counselling of parents and caretakers can go a long way in helping them tackle the emotional impact of this condition. While child counselling sessions help to assure the child, reinstate confidence and also infuse the belief that diabetes is a manageable condition, parental counseling seeks to allay the parents' fear regarding their child's future.

External sources of counselling
Depending on the extent of the psychological impact, counselling of the child is therefore not just desirable but even required. Although parents may be able to provide suchadvice, external help and counseling can effectively supplement the efforts of parents.

There are various counseling options available.
These are :
Family physician: The family physician is often the first line of support. The family physician will have an intimate knowledge of the child, his/her interests, and temperament. Further, the family physician enjoys the trust of the parents and the child alike. A talk with the family physician may be a timely confidence-booster.

Friends and family: Advice from friends and family, especially fellow-patients can also be very effective. A family member or friend who is successful and happy, despite such a diagnosis can be a very effective role model.

Online and offline support groups: Online support groups for both children and parents alike, provide a global network of support and also resources that the parents and child can tap into. Online support groups overcome the barriers of distance and allow parents to communicate, share and get answers to mutual concerns on bringing up a diabetic child.
Professional counseling: Where the emotional impact is deeper, professional counseling is not just desirable but required. Where thepsychological impact has resulted in mild or severe Depression,advice from a psychiatric professional is mandatory.
Tretment
Like MODS this Diabetes is too curable but here oral Medicines like Glipizide,Tolbutamide, Chlopropamide, Gliclazide,Glimperide etc.which stimulate Insulin production from Beta cell of Pnacreas does not work as Beta cells are absent in these children's pancreas,even Peripheral receptors stimulator like Metformin or Pio or Rosigliatazone or Repaglinide or Netaglinide or acrabose,Vobiglose,Majlitol,Vidagliptine or Sitagliptine does nor work.
Sole therapy is Injectable Insulin which may be porcine or Bovine Soluble insulin three times a day (used as cheap but leads to resistance and more lipidostophy ,now a days Human or recombinant tech E.Coli produced soluble Insulin three times or Protamin or Zinc insulin Suspension as Lente or UltraLente Insulin in various mixture proportion with Soluble Insulin 1-2 times used as subcutaneous injections at thigh or at belly part.Now a days prtamine fine preparation as Lispro Insulin and once used Insulin Glargin is used.Insulin Detemir or Expenta Injections are too used.Genetherapy and Stem cells are also coming with Pancreatic Beta cell transplant is also practised in developed rich countries.Insulin pump and Nasal Insulin spray is now also used in our country.

Conclusion
Dealing with diabetes is not just about taking medication, it is about dealing with its invisible and intangible effects. Counselling is one of themost potent tools that parents have to successflly manage the psychological consequences of this condition.
For stories on successful role models for children and more tips to young people on self management, coping and living with diabetes should be written and available to children sothat they never give away rather becomes more courageous to face it with change in life style,control over food and regular medicines and prevention of getting infected with infections and avoiding trauma to toes and nails with every care for any dental or any other minor sugical intervention.Such precautions will allow to lead the Child to lead a normal life with normal development ,activities,education and Social upbringing.
Dr.D.r.Nakipuria


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Aug30
WHEN IS SURGERY NEEDED FOR GALL BLADDER DISEASE?
Gall bladder functions as an optional storage for bile, secreted by the liver .It contracts to eject high concentration of bile into the intestine when a fatty meal is consumed. It does the same when any other meal is eaten. Its a mystery why we even have a gall bladder. Since patients who have had a cholecystectomy do well without it , it seems as if, its main function is to keep doctors busy ! Liver secretes bile acids that are important to make fat soluble before it is digested and absorbed in the intestine. It also secretes cholesterol and bilirubin into the bile.The cholesterol is not always stable and can crystallize to form stones. Also soluble bilirubin when converted to free bilirubin can precipitate. The problem starts when this cholesterol crystals and precipitated bilirubin settles and stores in the gall bladder as stones. Patients with gallstones will have unstable bile, have sluggish gall bladder activity and are more prone to nucleate crystals to grow into large stones.
It is not necessary that all patients with gall stones should undergo a surgery , and only those with symptoms should be offered surgery as they are at risk for complications. It is therefore the duty of a doctor to identify , categorize and correctly advise.In case of doubt , the patient should be referred to a specialist who deals with gall bladder problems and seek their advise. Unfortunately many patients undergo unnecessary surgery just because of an incidental finding on an ultrasound.On the other hand, patient with symptoms should not delay treatment as they are at risk of complications which at times , can be life threatening. True symptoms of gall bladder stones include, acute cholecystitis, biliary colic, jaundice and acute pancreatitis with elevated enzyme levels.Out of these, biliary colic announces that the stones are ready for treatment. When gall stones are proved to be the cause of severe symptoms, cholecystectomy is the best treatment. It cures biliary colic and prevents attacks of acute pancreatitis.But doctors should carefully categorize patients with and without symptoms and then offer their patients with the best option.


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Aug29
HEART : Act, before you are late
HEART : Act, before you are late

Dr.Gurvinder Pal Singh
Sutlej Hospital & Tavleen Heart Centre, Phagwara (Punjab)


Prevention is better than cure - This very old but time tested dialogue , particularly stands true for Coronary Artery Disease/ Ischeamic Heart Disease. Sedentary life, lack of exercise, faulty dietary habits, mental stress are the few main causes for rapid progession of plaque. We should not forget the role of smoking, tobbacco and alcohol.

Do we ever think that how much total exercise per day we are doing in the form of walking, jogging, swimming, playing badminton/table tenis etc or all the time we are totaly sedentary, mentaly tense, busy, using lift rather than staires or parking the car at the door of building rather than parking it 100yards away from the building so we can walk a little bit in the busy schedule.

Are we aware of our eating habits and follow a dietary plan. How much do we eat from our own Kitchen ( know what I am eating ) and how much from the Bakery and Restuarent. How much is the total intake of Fresh Fruits, Fresh Vegetables and Fibres and how much is Fast food. Bakery products have high contents of Salt and Hydrogenated fat/Trans fat along with class - II preservatives and colors and has almost no fibres.

Primary prevention is aim to identify an indivisual with multiple risk factors. Risk factors responsible for rapid progression of Atherosclerosis and CAD are-
Modifiable Risk Factors - Sedentary life, smoking, Obesity, Hypertension, Dyslipidemia, Diabetes and Insulin Resistance, Mental Stress.
Non Modifiable Risk Factors - Age , Sex, Family history, Genetic profile.
Atherosclerosis Risk Factors - Homocysteine, Fibrinogen, Lipoprotein-'a', LDL-C, Marker of fibrinolytic function, Marker of Inflamation( hs-CRP, ICAM & IL-6, PAI).

Universal screenig of all indians should be carried out for the purpose of of early detection of high risk indivisuals. A Screening Protocol should be addopted for detecting early CAD involvement and document the following --
*Name , Age, Sex
*Family history of premature CAD & CVD.
*Personal history of CAD & CVD.
*Dietary history.
*Body weight, Hieght, BMI & Waist circumference.
*Extent of physical exercise.
*History of smoking / tobbacco.
*Blood Pressure.
*Fasting Blood Sugar.
*Fasting Lipid Profile.
*Evaluation of metabolic Syndrome.
*For high risk indivisuals specificaly sreen for Intima Media Thickness ( CIMT ), Flow Mediated Vasodilatation ( FMD ), Aortic Root Calcium by (Echo), Coronary Calcium by (EBCT).

A recent survey shows high prevelance of cardio-metabolic syndrome in young physicians of india (JAPI). So, the Medical Professionals need to follow healthy lifestyle with minimum mental stress.

Primary prevention can be acheived by Early Diagnosis by Mass Screening, devloping Awareness, doing Counselling and proper Evaluation. Government, Health authorities, Public educators, NGOs and Media should come forward to teach the public a healthy lifestyle which is the first and powerful instrument to fight against Non - communicable Diseases like Coronary Artery Disease, Hypertension and Diabetes. Emphasis should be given to Regular exercise, Weight reduction, healthy eating habits, nutritional supplement, correcting dyslipidemia, controlling hypertension, cessation of smoking, overcome the mental depression and practice of Yoga by doing proper exercises of yoga.

Life Style management plays important role in the prevention of CAD. Life Style management should start from child hood. Fatty steaks /atherosclerotic leisons start devloping irreverisibly in early childhood and progress to in adoloscence and adulthood. A healthy childhood planning is essential to have a healthy adulthood. We should be beware of childhood obesity and eating habits of our kids. We can change our life style by changing our routine activities from sedentary to active life, food habits from refined to crude, control on risk factors and reducing mental stress for healthy future.


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Aug22
Date Palm Synovitis
Date Palm Synovitis

Date Palms




The date palm is common in the Sultanate of Oman and neighboring Gulf countries. The history goes back 600 years to Eridu in lower Mesopotamia where the first evidence of date cultivation has been found. Closer to this oasis, the Hilli settlements of Al-Ain in the Arabian Peninsula seems to be cultivated dates some 5000 years back. In Bidiyah, in the eastern region of the Sultanate of Oman, dates are the main-stay of the economy. Date growing is labor intensive in Oman and very traditional in its method.

To fertilize the female flowers (pistils), each date palm must be climbed and the pistils, which are clustered to the center of the leaves, pollinated. Each date palm provides the farmer with natural steps to climb the trunk. These are formed from the base of the previous season’s leaf stalks which were cut off. The technique of climbing is simple but since a date palm can be 30 meters tall, a key requirement is good head for height. The worker has to climb the tree once more in the later months in order to obtain the fruit that is now ready to be harvested.

Synovitis

Synovitis is the medical term for inflammation of the synovial membrane. This membrane lines joints which possess cavities, known assynovial joints. The condition is usually painful, particularly when the joint is moved. The joint usually swells due to synovial fluid collection.
Synovitis may occur in association with arthritis as well as lupus, gout, and other conditions. Synovitis is more commonly found in rheumatoid arthritis than in other forms of arthritis, and can thus serve as a distinguishing factor, although it can present to a lesser degree in osteoarthritis. Long term occurrence of synovitis can result in degeneration of the joint.

Date Palm Synovitis

Joint inflammation associated with intra-articular retention of a date palm thorn.

Synonyms

Date Palm Knee

Incidence

Uncommon in the northern hemisphere and in developed countries. It is much more common in Sultanate of Oman and neighbouring Gulf countries where traditional agricultural practices require climbing palm trees. Because the original injury may have been forgotten, this diagnosis should be considered in mono-articular inflammation in children.

Differential Diagnosis

Septic arthritis

( This can be differentiated by doing a simple blood investigation.
There will be normal WBC and ESR in Date Palm Synovitis, meanwhile in septic arthritis there will increase in both WBC and ESR)

Pathogenesis

A penetrating injury into the joint (usually the knee) results from a minor wound from a the thorn. The date palm tree bears thorns 10-15cm long, which can easily pierce the joint cavities.



If the thorn breaks off inside the joint, an acute, sub-acute or chronic inflammation of the joint may result. Many infective agents have been associated with date palm thorn. with no one predominating bacterium. Staphylococcus aureus has been found commonly but this is thought to be secondary infection following attempts at self-treatment.

Pathology

The arthritis may be either septic or sterile. It is unknown whether the primary features are due to infection or to an immune response to the foreign material in the vegetable matter. The reason for this is not clear, but alkaloids in the thorns are a possible cause (Stromqvist, Edlund and Lidgren 1985). The pathological features are those of acute inflammatory synovitis. Chronic synovitis develops if the condition persists.

Macroscopically,
• Redness, swelling, tenderness, loss of range of motion
• May settle to a chronic effusion with thickened boggy synovium
• May progress to a septic arthritis. There may also be a soft tissue infection leading to fasciitis. Examine for local, distant and systemic signs of infection – pyrexia, malaise, lymphadenopathy, cellulitis
• Rare presentation as locking, mimicking IDK with the thorn itself causing the locking




Microscopically,


Synovium from to two cases requiring partial synovectomy showed a non-specific synovitis. (Haematoxylin and eosin)



Synovial tissue from knee of patient with thorn-induced synovitis (hematoxyline- phloxine-saffron). Top: Heavy fibrin deposits (F) on surface and intenae infiltration of inflammatory cell (original maginification x 120, reduced approximately 25%). Bottom: Foreign material (arrow) in synovium, surrounded by numerous giant cells, seen under polarized light, material is highly refractile, consistent with plant thorn matter (original magnification x 540)

Stages

Acute
Infected
Inflammatory
Sub-acute (> 1 week)
Chronic
Non-specific

Classification

None encountered in the literature. Useful classifications could be devised using time, aetiological agent, infected/sterile or extent of the condition.

Clinical Features

Palm thorn synovitis is usually mild, the initial symptoms are often intolerated, delaying presentation for treatment.
The clinical features are:

• Puncture wound or history (may be absent)
• Redness, swelling, tenderness, loss of range of motion
• May settle to a chronic effusion with thickened boggy synovium
• May progress to a septic arthritis. There may also be a soft tissue infection leading to fasciitis. Examine for local, distant and systemic signs of infection – pyrexia, malaise, lymphadenopathy, cellulitis
• Rare presentation as locking, mimicking IDK with the thorn itself causing the locking

Investigation

CRP, aspiration and culture may identify an infective process and an organism but treatment of the infection may not resolve the problem unless the presence of the foreign body is detected. But normally, the WBC and ESR is within normal limits and no organisms was grown from any joint aspirate.

Depending on the stage fluid aspirated from the joint will have acute or chronic inflammatory cells but other rheumatological investigations will be negative.
Xrays are most often negative apart from a synovial effusion as thorns cannot be seen on radiographs. CT scan has been claimed to be diagnostic. MR scan is reliably diagnostic for this condition as the foreign body ( thorns) shows up well.

Prognosis untreated

In the acute infected case the prognosis is that of acute septic arthritis
For sterile cases and indolent infections the condition may settle to a chronic mono-arthritis with eventual secondary OA.
Since the condition is provoked by the presence of foreign material it will not settle completely until the foreign material is removed or eliminated.

Non-Operative Treatment

Appropriate antibacterial treatment.
Symptomatic treatment with analgesics and anti-inflammatory medication.
Steroid injection contra-indicated

Operative Treatment

Transarthroscopic excision of the loose body
Open or transarthoscopic synovectomy
Surgical treatment of septic arthritis

Complications

Chronic arthritis
Secondary OA
Sepsis

Outcomes

Favourable outcome after early recognition and surgical treatment
Literature suggests that synovectomy may be necessary after development of chronic synovitis i.e. that removal of the foreign body may not be enough.

Bibliography

1. Clough J.F.M. (1999) Cactus Knee Orthopaedic Rare Conditions Internet Database (ORCID) http://www.orthogate.org/orcid/aspercases.htm
Has an extensive bibliography on this subject

2. Maillot F, et al.
Plant thorn synovitis diagnosed by magnetic resonance imaging.
Scand J Rheumatol. 1994;23(3):154-5.


3. Doig SG, et al.
Plant thorn synovitis. Resolution following total synovectomy.
J Bone Joint Surg [Br]. 1990 May;72(3):514-5.

4. Klein B, et al.
Thorn synovitis: CT diagnosis.
J Comput Assist Tomogr. 1985 Nov-Dec;9(6):1135-6.


5. Ramanathan EB, et al.
Date palm thorn synovitis.
J Bone Joint Surg [Br]. 1990 May;72(3):512-3.

6. Olenginski TP, et al.
Plant thorn synovitis: an uncommon cause of monoarthritis.
Semin Arthritis Rheum. 1991 Aug;21(1):40-6.


7. Vaishya R.
A thorny problem: the diagnosis and treatment of acacia thorn injuries.
Injury. 1990 Mar;21(2):97-100.

8. Adams CD, Timms FJ, Hanlon M.
Phoenix date palm injuries: a review of injuries from the Phoenix date palm treated at the Starship Children's Hospital. Aust N Z J Surg. 2000 May;70(5):355-7.


9. Miller EB, Gilad A, Schattner A.
Cactus thorn arthritis: case report and review of the literature.
Clin Rheumatol. 2000;19(6):490-1.

10. Labbe JL, Bordes JP, Fine X.
An unusual surgical emergency: a knee joint wound caused by a needlefish. Arthroscopy. 1995 Aug;11(4):503-5.

This article was contributed by Ms Maisrah as an e learning exercise


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Aug22
FROZEN SHOULDER IN DIABETICS
FROZEN SHOULDER IN DIABETICS
When we ponder upon diabetes mellitus and its complications, we might be imagining conditions like diabetic foot, renal failure, atherosclerosis, diabetic retinopathy and so on. Shoulder problems are not what come to mind when most people think of diabetes. But studies have found a link between both types of diabetes and a condition known as frozen shoulder.
The incidence of frozen shoulder has been estimated to be from 3% to 5% in the general population, with a significantly increased incidence amongst diabetics, on the order of
10% to 20%. It appears to be most common in adults between the ages of 40 to 70 years. Women appear to be at a slightly increased risk (4:1) and the non-dominant arm is most commonly affected. Idiopathic frozen shoulder is most strongly associated with insulin-dependent diabetes, in which the lifetime risk of developing adhesive capsulitis may be as high as 36%, with the first episode occurring at a significantly younger age than in the general population. Non-insulin-dependent diabetics also have an increased incidence of frozen shoulder, but not as high as in insulin users. Diabetics also have a tendency to develop bilateral shoulder involvement. Therefore, patients who present with a somewhat atypical set of findings should be screened for diabetes as part of their initial workup.
So, what is a frozen shoulder actually? A frozen shoulder is a shoulder joint with significant loss of its range of motion in all directions. The range of motion is limited not only when the patient attempts motion, but also when the doctor attempts to move the joint fully while the patient relaxes. A frozen shoulder is also referred to as adhesive capsulitis. The modern English words "adhesive capsulitis" are derived from the Latin words adhaerens meaning "sticking to" and capsula meaning "little container" and the Greek word itis meaning "inflammation". The shoulder is the most mobile joint in the body. Its function is to position the arm in space to reach out to objects and deliver them for other actions. The shoulder is a ball and socket joint formed by the upper end of the humerus (arm bone) and the socket formed by the glenoid of the shoulder blade. It is lined by a bag like capsule. The capacity of this joint is about 15- 20 cc. In frozen shoulder the capacity is reduced to 2- 3 cc. The movements at the shoulder joint occur synchronously with that at joint between the shoulder blade and the torso and are compensated to some extent by this.




A few theories had been put forth by a number of physicians and researchers to explain the link between frozen shoulder and diabetes mellitus. Dr. Aaron Vinik, MD, PhD who is the Director of Diabetes Research Institute in Eastern Virginia Medical School, Norfolk, Virginia said that certain compounds accumulate in the linings of joints in the collagen. The collagen fibers then stick together and limit the capacity for the joint and ligaments to stretch with movement. Ultimately this ends up as a frozen shoulder. Agreeing with the fact, Dr. Richard Bernstein of the Diabetes Center Mamaroneck, New York offers his perspective on frozen shoulder:
Muscular and skeletal problems are virtually universal among people with long-standing, poorly controlled diabetes. Sometimes the problems are very painful and even disabling. They probably stem from glycosylation of collagen (a protein in tendons).
Collagen fibers normally slide along one another during muscular movement. In glycosylation, they become glued together by glucose. This process can also occur in the skin, which becomes hard and tough (diabetic scleredema).
In another studies, Neviaser and Neviaser in 1945 coined the name "adhesive capsulitis" to suggest an adhesive process of the capsule to the humeral head and was first termed by. However, this name appears to be somewhat of a misnomer, as later shown by later arthroscopic evaluations. What has been found is a contracture that consists of thickening and fibrosis within the joint capsule itself. This process results in decreased intra-articular volume and diminished capsular compliance, so that glenohumeral motion is limited in all planes. Normal intra-articular volume is about 15 to 30 cc; in patients with adhesive capsulitis, the joint capacity is typically less than 10 cc.
Histologically there has been some controversy regarding the etiology of the fibrosis and contracture of the capsule. In original studies done by Neviaser there was evidence of synovial inflammation. In separate studies, however, Bunker suggested that the active pathologic process is that of fibroblastic proliferation. Interestingly, it appears that the histologic changes are very similar to Dupuytren's contracture, which is also associated with diabetes.
Meanwhile, recent advances discovered that the answer to frozen shoulder lies in the genes. These genes may also be associated with Diabetes mellitus. The alterations in these genes and chromosomes lead to a distorted response to wound healing and scar tissue formation. Exuberant scar tissue forms in response to trauma. The remodeling of scar tissue collagen is less. When more scar tissue forms in the capsule of the shoulder joint, the normally possible movements are grossly reduced. Diabetics also develop nodules in their palms and feet, another evidence of the exaggerated healing process.
Whatever it is, the pathophysiology of frozen shoulder in diabetics remains elusive. What can be said is that, there is a positive evidence to link the excessive level of glucose in the blood and the process of glycosylation of the collagen fibers to be responsible in the development of frozen shoulder.
Classically, the frozen shoulder has been described as occurring in 3 stages:
(1) painful, (2) stiff, and (3) resolving. The natural course of these phases
typically takes from 1 to 3 years to resolve. The first phase often begins
with pain in the shoulder. Patients will complain of pain while sleeping on
their side and will self-restrict the movement of their shoulder to their side
in order to avoid pain. They often complain of generalized pain in the deltoid
region. Often, patients will not seek medical attention during this phase,
expecting that the pain will resolve on its own. They may self-medicate with
analgesics, and will only present when the restriction of motion becomes problematic.
There is usually no inciting trauma or other event, although patients may remember
the specific moment when they were unable to do a particular activity due to
restricted motion. The painful phase may last from 2 to 9 months.
In the stiff or frozen phase, the shoulder is significantly
restricted, and patients note the inability to perform daily functions, especially
those that require significant internal or external rotation or elevation (e.g.
hair washing, reaching overhead). Patients often present at this point with
very specific complaints, such as an inability to scratch their back, fasten
their bra, or get an item from an overhead shelf. When moving within the limits
of their motion, the patient has little or no pain. It is only when the patient
attempts an activity that requires motion beyond their capability that they
develop "end-range pain." The frozen stage can last for 3 months
to 1 year.
In the resolution phase, the "thawing" begins and the patient gradually regains some range of motion. The ability to perform functional activities improves over 1 to 3 years; however, full range of motion is rarely recovered. On long-term follow-up (even up to 11 years later), up to 60% of patients appear to have persistent restriction. What is notable is that loss of less than 20% of the normal range of motion does not appear to affect activities of daily living, nor cause significant functional disability.
How a frozen shoulder is usually diagnosed? A frozen shoulder is suggested during examination when the shoulder range of motion is significantly limited, with either the patient or the examiner attempting the movement. Underlying diseases involving the shoulder can be diagnosed with the history, examination, blood testing to exclude any endocrine disorders e.g. hyperthyroidism, and x-ray examination of the shoulder.
If necessary, the diagnosis can be confirmed when an x-ray contrast dye is injected into the shoulder joint to demonstrate the characteristic shrunken shoulder capsule of a frozen shoulder. This x-ray test is called arthrography. Arthrogram contrasts are special x-rays that show details of the shoulder capsule, such as a decrease in size (in a normal shoulder the capsule is rounded, but in a frozen shoulder the capsule is squat, square and contracted).

The tissues of the shoulder can also be evaluated with an MRI scan. The MRI findings that suggest adhesive capsulitis include soft tissue thickening in the rotator interval, which may encase the coracohumeral and superior glenohumeral ligaments, and soft tissue thickening adjacent to the biceps anchor. Other findings that can be demonstrated on MRI include thickening of the inferior glenohumeral ligament greater than 4 mm and loss of definition of the inferior capsule secondary to edema and synovitis.






The aim of treatment for frozen shoulder is to alleviate pain and preserve mobility and flexibility in the shoulder. However, recovery may be slow, as symptoms tend to persist for several years. Treatment options for frozen shoulder include painkillers to relieve symptoms of pain. Nonsteroidal anti - inflammatory drugs (NSAIDs), such as ibuprofen, are over - the - counter (OTC, no prescription required) painkillers and may reduce inflammation of the shoulder in addition to alleviating mild pain. Acetaminophen (paracetamol, Tylenol) is recommended for extended use. Prescription painkillers, such as codeine (an opiate - based painkiller) may also reduce pain. Not all painkillers are suitable for every patient; be sure to review options with doctor.
Exercise which is frequent and gentle can prevent and even reverse stiffness in the shoulder. Vigorous activity involving shoulder joint should be hindered to prevent more injury from occurring at the site and thus slowed down the healing. Hot or cold compression packs may help to reduce pain and swelling. It is often helpful to alternate between the two.
Corticosteroid injection is a type of steroid hormone that reduces pain and swelling. Corticosteroids may be injected into the shoulder joint to alleviate pain, especially in the 'painful stage' of symptoms. However, repeated corticosteroid injections are discouraged as they could cause damage to the shoulder. It is also a diabetogenic hormone which is not so preferably good choice of treatment for frozen shoulder in diabetics.
Transcutaneous electrical nerve stimulation (TENS) numbs the nerve endings in the spinal cord that control pain and sends small pulses of electricity from the TENS machine to electrodes (small electric pads) that are applied to the skin on the affected shoulder.
Physical therapy or physiotherapy session can teach exercises to maintain as much mobility and flexibility as possible without straining the shoulder or causing too much pain. Physiotherapy in the form of gentle, firm stretching exercises in various planes of motion has been proven to be effective in the relief of pain and in recovery of range of motion in up to 90% of patients with idiopathic frozen shoulder.
Ultrasound can speed the recovery of a frozen shoulder injury significantly by breaking down the scar tissue around the shoulder joint. Using ultrasound on a regular basis or throughout the day will help relax the shoulder muscles, tendons and tissues, diminish pain and inflammation, soften scar tissue and contribute greatly to the healing of injury.
For a resistant frozen shoulder or if patient has poor compliance to the aforementioned regiments, shoulder manipulation can be used as an alternative. The shoulder joint is gently moved while patient is under a general anesthetic. Another way is shoulder arthroscopy - a minimally invasive type of surgery used in a small percentage of cases. A small endoscope (tube) is inserted through a small incision into the shoulder joint to remove any scar tissue or adhesions.
As a conclusion, most patients who present with a restriction of shoulder motion with history of diabetes mellitus and no significant history of trauma to the shoulder may fall under the category of frozen shoulder. This fact can help the clinician to choose an appropriate treatment regimen. Patients diagnosed with the idiopathic form of adhesive capsulitis should be put on a gentle stretching regimen, and counseled about the natural history of the disease, which can take many months to resolve. All of the above treatments absolutely work if properly performed with the right equipment. But, if blood sugar remains elevated, such problems will in all likelihood recur.

REFERENCES:
1. http://www.medicinenet.com/frozen_shoulder/article.htm
2. http://www.diabeteshealth.com/read/1999/11/01/1702/how-is-frozen-shoulder-associated-with-diabetes/
3. http://www.med.ucla.edu/modules/wfsection/article.php?articleid=233
4. http://EzineArticles.com/?expert=Alampallam_Venkatachalam
5. http://www.nlm.nih.gov/medlineplus/ency/article/000455.htm
6. http://www.deccanchronicle.com/health/diabetes-can-lead-frozen-shoulder-571
7. http://www.cnn.com/HEALTH/library/frozen-shoulder/DS00416.html
8. http://www.diabeteshealth.com/read/1999/11/01/1702/how-is-frozen-shoulder-associated-with-diabetes/
9. http://www.medicalnewstoday.com/articles/166186.php


This article is excerrpted from
: Orthopedic and Rheumatological afflictions in Diabetes Mellitus A review - Paperback (July 30, 2010) by Gourishankar Patnaikhttp://www.amazon.com/Musculoskeletal-Manifestations-Diabetes-Mellitus-Rheumatological/dp/363928089X/ref=sr_1_1?ie=UTF8&s=books&qid=1282478501&sr=8-1


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Aug22
ORTHOPEDIC MANIFESTATIONS DURING PREGNANCY
ORTHOPEDIC MANIFESTATIONS DURING PREGNANCY

Almost all pregnant women experience musculoskeletal discomfort during pregnancy,
with a good portion of them suffering from severe disability. The enlarging gravid uterus alters
the maternal body's center of gravity, mechanically stressing the axial and pelvic systems, and compounds the stresses that hormone level fluctuations and fluid retention exert. While the pregnant woman
is prone to many musculoskeletal injuries, most can be controlled conservatively, but some require emergent surgical intervention.

Often, the source of these musculoskeletal problems can be traced to an endocrine disorder.
For example, carpal tunnel syndrome is not uncommon in patients who are pregnant or
have diabetes, hypothyroidism, or acromegaly. Joint problems and arthritis
are other common findings in diabetes, pregnancy, and hyperparathyroidism. Muscle weakness or stiffness is seen in both hypothyroidism and hyperthyroidism, and muscle wasting is a characteristic of adrenocorticoid insufficiency. Bone disorders are common with glucocorticoid excess, acromegaly, and hyperparathyroidism. Some presentations are a classic picture of a specific endocrine condition and are readily recognized if the index of suspicion is appropriately high.

During pregnancy, certain anatomical and hormonal changes occur that produce
increased stress on the pelvic
articulations resulting in the development of pelvic girdle relaxation. Pelvic girdle relaxation during pregnancy is physiological and is caused by hormonal and biomechanical factors. When a pregnant woman presents as
a patient with low back or pelvic pain, walking dysfunction and with reproduction
of pain with sacroiliac provocation, the diagnosis of symptomatic pelvic girdle relaxation can be madeThe gravid uterus
and the compensatory lordosis that it
causes create a tremendous mechanical
burden on the lower back. Joint laxity increases during pregnancy. The hormone relaxin has been identified as a major contributor to joint laxity during pregnancy. It decreases the intrinsic strength of the connective tissue allowing it to expand and lose its rigidity, resulting in increased widening and sliding mobility of the joints, thus causing potential instability. This occurs especially in the ligaments of the sacroiliac and pubic symphysis joints,
but may also occur in peripheral joint.
This may result in pubic symphysis pain,
low back pain or hip pain.

Pubic Symphysis Pain

Pathology: Separation of the pubic symphysis joint (diastasis or symphysiolysis), as a result of pelvic girdle relaxation, is thought to be the main cause of pubic symphysis pain. Relaxin levels were found
to be significantly higher in pregnant
women with pelvic pain and joint laxity.
The highest level was found in those women with the most severe clinical symptoms, who also took a longer time to recover after pregnancy. Swelling within the joint, ligament disruption and hemorrhage have
also been suggested to cause pubic symphysis pain. The severity of these conditions varies from mild self-limiting pain to a severe disabling condition. Lack of awareness and failure of recognition of these complications by obstetricians not only results in women feeling very lonely and misunderstood, but may also result in long-term morbidity.

Presentation: Patients may present during pregnancy (usually in the second or third trimester), during labour or 24-48 hours postpartum, with a sudden or insidious
onset of pain of variable severity in the pubic area or groin which may radiate to
the medial aspect of the thigh and increases on weight-bearing. Pain may occur also in the hips, suprapubic area or the lower back and be aggravated by walking, standing, stairs climbing, parting of the legs or turning in bed.

Clinically, a waddling gait or limp may be noticed. The woman may not be able to stand comfortably on one leg. Abduction of the thigh is usually painful. Point tenderness in the region of the pubic symphysis and pain on compression of the pelvis by simultaneous pressure on both trochanters are usually present. Care must be taken as exquisite pain may occur on palpation of
the pubic symphysis, which may also reveal
a gaping pubic defect and edema.

The symptoms (and their severity) experienced vary, but include:

. Present swelling and/or inflammation over joint.

. Difficulty lifting leg.
. Pain pulling legs apart.
. Unable to stand on one leg.
. Unable to transfer weight through pelvis and legs.

. Pain in hips and/or restriction of hip movement.

. Transferred nerve pain down leg.
. Can be associated with bladder and/or bowel dysfunction.

. A feeling of symphysis pubis giving way.
. Stand with a stooped over back.
. Mal-alignment of pelvic and/or back joints.

. Struggle to sit or stand.
. Pain may also radiate down the inner thighs.

. You may waddle or shuffle.
. Aware of an audible ‘clicking’ sound coming from the pelvis.

Psychosocial impact - interferes with participation in society and activities of daily life; the average sick leave due to posterior pelvic pain during pregnancy is 7 to 12 weeks. In some cases patient may also experience emotional problems such as anxiety over the cause of pain, resentment, anger, lack of self-esteem, frustration and depression; she is three times more likely to suffer postpartum depressive symptoms. Other psychosocial risk factors associated with woman experiencing PGP include higher level of stress, low job satisfaction and poorer relationship with spouse.

Diagnosis of pubic symphysis separation is based on the clinical presentation and the response to therapy. Imaging (X-ray, ultrasound o r magnetic resonance [MRI])
may be useful in confirming the diagnosis. Ultrasound examination using a 7.5 MHz or 5 MHz linear array transducer may demonstrate widening of the interpubic gap in excess of 10 mm. Ultrasound has many advantages over conventional X-ray, as it can be done during pregnancy and can be repeated safely for follow-up. However, the amount of symphyseal separation does not always correlate with the severity of the symptoms, or the degree of disability, nor does it appear to
predict outcome.

Severity - The severity and instability of the pelvis can be measured on a three level scale.

Pelvic type 1: The pelvic ligaments support the pelvis sufficiently. Even when the muscles are used incorrectly, no complaints will occur when performing everyday activities. This is the most common situation in persons who have never been pregnant, who have never been in an accident, and who are not hyperactive.
Pelvic type 2: The ligaments alone do not support the joint sufficiently. A coordinated use of muscles around the joint will compensate for ligament weakness. In case the muscles around the joint do not function, the patient will experience pain and weakness when performing everyday activities. This kind of pelvic often occurs after giving birth to a child weighing 3000 grams or more, in case of hyperactivity,
and sometimes after an accident involving the pelvis. Type 2 is the most common form of pelvic instability. Treatment is based on learning how to use the muscles around the pelvis more efficiently.

Pelvic type 3: The ligaments do not support the joint sufficiently. This is a serious situation whereby the muscles around the joint are unable to compensate for ligament weakness. This type of pelvic instability usually only occurs after an accident, or occasionally after a (small) accident in combination with giving birth. Sometimes a small accident occurring long before giving birth is forgotten so that the pelvic instability is attributed only to the childbirth. Although the difference between Type 2 and 3 is often difficult to establish, in case of doubt an exercise program may help the patient. However, if Pelvic Type 3 has been diagnosed then invasive treatment is the only option: in this case parts of the pelvic are screwed together.

Treatment: One of the main factors in helping women cope with the condition is with education, information and support. Other coping strategies include physical medicine and rehabilitation, physiotherapy, osteopathy, chiropractic, psychologist, prolo therapy or platelet-rich plasma therapy, massage therapy, acupuncture and alternative medicine. Mobility aids such
as a wheelchair, walker, elbow crutches
and walking stick can be very useful. Medication dispensed by a qualified health care provider can also be used to manage:

• Chronic pain
• Anxiety
• Depression
• Post Traumatic Stress Disorder (resulting from birth trauma/ pregnancy)
• Musculo-skeletal disorders.

Conservative treatment is effective in most cases, including those women with the most severe symptoms at presentati0n. A clear explanation of the condition and its management, to both the woman and her partner, is vital. The aim is to avoid abduction of the hip joint and encourage immobilization of the pubic symphysis joint. In cases presenting during pregnancy or after birth, women should be advised to rest as much as possible in the lateral decubitus position: avoid prolonged weight bearing and stairs and keep her legs together in activities such as turning in bed or getting into a car. Since immobilization is a primary risk factor for deep vein thrombosis, isometric exercises should be encouraged. Anti-embolism stockings and heparin may be required. Analgesics can be given on demand. If the above measures fail to improve the
symptoms, referral to an obstetric physiotherapist should be arranged. Pelvic support by a tight binder or tubular
bandage and the use of a walker or elbow crutches may be required. The maximum hip abduction possible without pain (pain-free gap) should be measured before labour, to avoid over-abduction of thighs in labour, especially when regional anesthesia is
used. Some pelvic joint trauma will not respond to conservative type treatments
and orthopedic surgery might become the
only option to stabilize the joints.

Surgery is rarely indicated, but may be considered for those who have inadequate reduction, recurrent diastases or
persistent symptoms. External skeletal fixation is the treatment of choice. The symphysis is compressed using a frame
which can be removed once stability has returned. Prognosis is uniformly good.
Mild cases typically resolve within 2 days to eight weeks of delivery with no lasting sequelae. However, some women require as much as eight months before they are free
of pain when walking. During this time the pain may be worse during the secretory phase of the menstrual cycle. In a recent survey of Norwegian women registered as having pregnancy-initiated pelvic joint pain, it was found that pelvic pain worsened with subsequent pregnancy in 81.4% of the responding. However, in the absence of specific obstetric indications, prior pubic symphysis separation should not be considered a strong indication for subsequent operative delivery.

Low Back Pain

Pathology: Symptomatic back pain in pregnancy is caused by the mechanical
burden created on the lower back by the pregnant uterus and compensatory lordosis. Relaxation of the sacroiliac joint and
pubic symphysis plays an important part.
The highest levels of relaxin during pregnancy have been found in women with incapacitating low back pain. Very occasionally, low back pain may be attributable to a herniated vertebral disc.
Presentation: The usual presentation is
that of low back pain or posterior pelvic pain that is aggravated by activity and relieved by lying down, sitting and the use of supportive pillow. The pain may radiate to the posterior aspects of the thighs. Examination reveals accentuation of the lumbar lordosis and the cephalad part of
the spine thrown backwards to compensate
for the increased size of the abdomen. Tenderness is usually greatest over the sacroiliac joints. Indirect bimanual compression over the iliac crest also produces discomfort in the sacroiliac
joints.

Management: Each patient should be questioned carefully about neurological compromise as very occasionally radicular signs or even a cauda equina syndrome may
be identified. Most patients with classic symptoms and signs limited to low back strain or sacroiliac instability can be managed without radiographic evaluation. Radiographic evaluation of patients with unusual or severe symptoms may be carried out after the first trimester and can include a three view spine series. However, MRI appears to be a safe way to image the pelvic regions during pregnancy and will give direct information about any disc prolapse without irradiation. This should now be the investigation of choice if indicated.

Treatment: Relief of symptoms of low back pain in pregnancy can be achieved by the patient limiting her physical activity, wearing low-heeled shoes, resting in bed with pillows under the knees and applying heat. Lying on the back with the feet propped approximately two feet above the hips for about 20 minutes four times a day usually relieves muscle spasm, decreases lumbar lordosis and relieves acute pain.
In addition, the pain can be partially relieved if the patient keeps the pelvis
in a flexed position, thereby improving spinal alignment. Exercise to increase the tone of the back and abdominal muscles should be commenced as soon as the pain decreases. A sacroiliac corset or trochanteric belt can relieve symptoms. Surgical treatment of low back pain is contraindicated in pregnancy, except when
a herniated disc is producing bowel or bladder incontinence. Pain relief can be achieved with simple analgesics but anti-prostaglandins are relatively contraindicated in pregnancy.

Hip Pain

Two relatively rare conditions, osteonecrosis of the femoral head and transient osteoporosis of the hip, both
seem to occur with somewhat greater frequency during pregnancy and present with pain in the hip or groin. The diagnosis of these conditions is often missed initially because pain is easily taken for pelvic girdle relaxation or round ligament pain. Early diagnosis and treatment are the keys for a successful outcome and prevention of secondary degenerative changes or fracture in the joints of these young women.

1) Osteonecrosis of the femoral head
Presentation: Symptoms usually begin in the third trimester or shortly after a difficult delivery, with sudden or gradually increasing pain of variable severity, usually unilateral and deep in the groin. The pain may radiate to the knee, thigh or back. Elderly primigravida are most at risk. On examination, painful limitation of
active or passive movements of the hip joint, especially with movement, can be noticed. The exact aetiology is not known. But it has been speculated that the rise in unbound cortisol, oestrogen and
progesterone in late pregnancy, the increased interosseous pressure and a
direct injury to the femoral joint by the compression of the growing uterus or during a difficult delivery may all act together
to produce insufficiency of blood supply
to the fernoral head at some point.

Management: Plain radiography may demonstrate arc-like subchondral
radiolucent areas and other pathological changes in the femoral head, but MRI has been used recently for earlier diagnosis with apparent safety during pregnancy.
Early diagnosis, rest and avoiding weigh-bearing are very important. Aspiration of the hip joint may occasionally be
required. The prognosis after early diagnosis and conservative treatment
seems to be good, although secondary degenerative or osteoarthritic changes
may develop and require surgical treatment at a later age.

Figure: Subchondral separation Figure: Osteonecrosis of femoral head on plain X-ray

2) Transient osteoporosis of the hip
Presentation: This is a poorly understood and frequently undiagnosed syndrome of unknown aetiology. It occurs in the third trimester and presents with pain in the
hip, anterior thigh or groin, which progressively increases and is made worse
by weight-bearing. The left hip is more frequently involved but bilateral involvement can also occur. On examination, pain and limitation of range of mobility on passive abduction and rotation of the affected joint is usually noticed.

Management: X-rays of the hip show advanced osteoporosis of the femoral head and neck and, occasionally, the acetabulum, but
with preservation of the joint space. These changes are present three to eight weeks after the onset of symptoms. MRI can be
use for early diagnosis. Bone mineral density (BMD) of the femoral neck of symptomatic women has been shown to be 20% lower than the average of age-matched controls. The great concern with regard
to this disorder is that continued unprotected weight-bearing can result in
a fracture of the femoral neck. The aim
of treatment is to avoid unprotected
weight bearing by the use of crutches until the symptoms resolve completely and radiography shows reconstitution of bone
in the proximal part of the femur. Given
the decrease in BMD that occurs during pregnancy and lactation, it might appear prudent to recommend cessation of lactation in these patients.

During pregnancy, circulating total calcium concentration drop slowly but consistently and parallel with decreasing albumin concentration. Reaching a nadir in the middle third of the third trimester. An early hypothesis was that pregnancy is a state of maternal physiologic hyperparathyroidism. According to this theory, transfer of calcium to the fetus induces secondary hyperparathyroidism
in the mother, which leads consequently
to increased 1,25-dihydroxyvitamin D production. Another theory says the
increase in circulating levels of 1, 25-dihydroxyvitamin D is the primary
event in calcium metabolism alterations during pregnancy, subsequently stimulating intestinal calcium absorption and possible additional effects on other target tissues. With these alterations in calcium metabolism, pregnancy may exacerbate or simply coexist with the number of
conditions that may result in maternal hypercalcemia. These conditions include primary hyperparathyroidism, vitamin A or
D intoxication, systemic sarcoid, hyperthyroidism, milk-alkali syndrome, familial hypocalciuric hyoercalcemia, immobilization, malignancy with or without bone metastasis or ectopic PTH secretion.
On the other hand, alterations in calcium and parathyroid hormone metabolism may
also results in hypoparathyroidism and hypocalcemia. Hypoparathyroidism results from inadequate secretions of PTH or defective production of biologically active PTH. Pseudohypoparathyroidism results from end-organ insensitivity to the hormone.
The diminished PTH activity in the kidney and bone leads to hypocalcemia and hyperphosphatemia. Patient with mild hypoparathyroidism may be asymptomatic or may experience only subtle manifestation
of the disease. In more severe forms of the disorder, symptoms and signs related to decreased serum ionized calcium concentrations may occur. Increased neuromuscular excitability, which can be elicited on physical examination by a positive result for Chovstek's sign
(tapping along facial nerve including contractions of the eye, mouth and nose)
or Trousseau's sign (inflating a blood pressure cuff above systolic pressure causing spasm of the hands within minutes), can uncommonly progress from weakness and paresthesia to the development of seizures, tetany, or laryngospasm. Papilloedema, elevated cerebrospinal fluid pressure and neurologic sign that mimic a cerebral
tumor may be found. A spectrum of mental status changes, from irritation to psychosis, can occur. Abnormalities in the cardiac conduction, particularly prolongation of
QT interval and T wave changes, may be present. Radiographs of the skull may demonstrate intracranial calcifications, which are sometimes associated with a parkinsonian-like syndrome. Additionally,
if the disease has been long standing, physical examination may reveal dental abnormalities or cataracts.
Untreated maternal hypoparathyroidism with its associated hypocalcemia leads to a high incidence of maternal, fetal and neonatal complications. Generalized skeletal demineralization, osteitis fibrosa cystica and fetal or neonatal death can occur. Although the secondary hyperparathyroidism is transient and generally resolves in the neonatal period, the infant may not
achieve normal bone mineralization until
6 months of age.

Deficiency of vitamin D and disorders of vitamin D absorption or metabolism can
lead to hypocalcemia and also to
subsequent disorders of bone
mineralization, such as osteomalacia and tetany. Derangements in vitamin D
metabolism may also explain the osteopenia associated with heparin treatment during pregnancy.

References:

1. Medical Complications During Pregnancy by Burrow and Duffy 5th edition

2. http://en.wikipedia.org

3. http://www.maitrise-orthop.com /corpusmaitri/orthopaedic/mo72_hernigou/index.shtml

4. http://www.ncbi.nlm.nih.gov/pubmed/18199383?dopt=AbstractPlus

5. http://www.ncbi.nlm.nih.gov/pubmed/1946104?ordinalpos=1&
itool=EntrezSystem2.PEntrez.Pubmed. Pubmed_ResultsPanel.Pubmed_ SingleItemSupl.Pubmed_ Discovery_RA&linkpos=4&log$=relatedreviews &logdbfrom=pubmed

N.B. This article was contributed by Medical Student Ms Azreena Baizura bt Ariffin from Melaka Manipal Medical College , Malaysia as an E learning Exercise.


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Aug22
Simultaneous involvement of larynx and middle ear in pulmonary tuberculosis
Case report "Simultaneous involvement of larynx and middle ear in pulmonary tuberculosis" By dr Khan, dr Parab & dr Ghaisas is published in international Journal The Laryngoscope. The link is :
http://onlinelibrary.wiley.com/doi/10.1002/lary.21029/abstract


http://onlinelibrary.wiley.com/doi/10.1002/lary.21029/abstract

Simultaneous involvement of larynx and middle ear in pulmonary tuberculosis - Parab - 2010 - The Lar
onlinelibrary.wiley.com
Parab, S. R., Khan, M. M. and Ghaisas, V. S. , Simultaneous involvement of larynx and middle ear in pulmonary tuberculosis. The Laryngoscope, n/a. doi: 10.1002/lary.21029


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Aug20
Oral Mucositis
Oral Mucositis
Refers to erythematous &ulcerative lesions of oral mucosa observed in the patients with cancer being treated with Chemotherapy and radiotherapy
Lesions are often very painful &compromise nutrition &oral hygiene &as well as increase risk for local&systemic infections
It also involve other areas of the alimentary tract for eg—GIT mucositis can manifest as diarrhea
Oral mucositis initially presents as a erythema of the oral mucosa which then often progresses to erosion and ulceration. The ulcerations are typically covered by a white fibrinous pseudomembrane. The lesions heal within approximately 4-6 weeks after the last dose of somatotoxic chemotherapy or radiation therapy
Several factors affect the clinical course of mucositis Lesions are usually limits to non-keratinized surfaces ie lateral and ventral tongue,, buccal mucosa &soft palate .Ulcers arise within 2 wks after initiation of therapy The cinical severity is directly proportional to the dose of radiation administered .Most patients who have received more than 5000cGy to the oral mucosa will devlop severe ulcerative oral mucositis
Clinical course of oral mucositis may sometimes be complicated by local infections such as Herpes - simplex and fungal infections such as candidiasis
Management of oral mucositis has been largly palliative
Primary symptom pain affects nutritional intake ,,mouth care &quality of life.. Thus pain management is of upmost imp in this case .. saline gargles ,,ice chips,,&topical mouth rinse contaning lidocaine an anesthetic agent can be used
Nutritional intake can be severly compromised by pain& in addition taste change also occur after chemo,, radiotherapy,, It is essential to monitor nutritional intake &weight .A soft diet ,, liquid diet when oral mucositis present
TREATMENT OF DRY MOUTH---Patients undergoing cancer therapy suffer from xerostomia (Dry mouth) or hyposalivation can further aggrevate inflamed tissues &increase local infection &make mastication difficult &aggrevate the oral mucositis . hence treatment for such conditions should also be considered
A--- chewing of sugarless gum to stimulate flow
B ---use of cholinergic agents as necessary
C ----adv to sip water frequently allieviate dry—
TREATMENT OF BLEEDING---In the patients who are thrombocytopenic as a result of high dose chemotherapy ,, bleeding may occur from ulcerative oral mucositis This can usually be controlled by local hemostatic agents such as fibrin,,glue or gelatin spongue
Oral mucositis is a clinically imp &sometimes dose limiting complication of cancer therapy
Clinical management is largly focused on palliative measure such as pain management ,, nutritional support& maintanaince of good oral hygiene


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Aug20
CANCER-DEATH / DISABILTY / DRUG DEPENDANCE ----ARE THEY ASSOCIATED ?HOW TO FIGHT IT?
CACANCER-DEATH / DISABILTY / DRUG DEPENDANCE ----ARE THEY ASSOCIATED ?HOW TO FIGHT IT?

Cancer ,word it self fetches us to a very frieghtening and fearful meaning,if ,unfortunately somone in our family or society is being suspected or suffering from it and the word "CANCER" comes beore us in any way ,we start presuming very badly and gets completely shocked and nervous assuming that person concerned is very very seroius and his /her days are almost in counting scale and we became wholly sympathetic for that person forgetting every his/her adversary towards us and try to help the person as far as possibly by money,service or any other means if possible.But in real Biological sense "CANCER" is not that kind of Lion or Tiger that once you face it there is no hope of life and certainly it is not curable and we should be completely depressed and hopeless becauuse many "CANCERS" are now completely curable and life becomes as normal as it was without it ,only thing is that it should be detected as early as possible and treatment should be started as soon as possible.It is commonly believed that once Cancer means we,shall be never cured from this ,we have to take medicine regularly throughout the life,and we donot know when recurrence may occur and again mor discomfort or Death may come to us any time,person has to be in screening throughout the life moving to Hospital or doctor almost off and on throughout the life.Yes,for some persons these lines are true but in many cases these are simple myths ,Cancer once cured,never recurs or recur in so less percentage that one has nothing to worry,even follow up of symptoms noticing is important,that is with every disese once one suffers from cold or cough or diarrhoea one goes to Doctor,same way here one has to go to Doctor,no test or investigations are required and life becmes as normal as it was originally without Cancer,so nothing to worry,be happy,never get depressed or shcoked by this word,cancer, never loose heart face it at first meeting boldly and fight so well that finish it nipped into bud.As the modern science is growing and more and more reaseaches are done and treatment bieng enforced to treat Cancer by means of better chemotherapeutics or medicines with very less sideeffects,Monoclonal Antibodies,different caccines,interferons and Stem cell with development of Gene therapy ,better rays inform of Positron euipped with Ct scan and MRI or Tomography machine,Cyber knief,Brain Suits,or IMRT or Brachytherapy, Stereotactic Radiotherapy beside cobalt ,gamma and X-rt with linear acceletor and modern Surgical removl of cancer using ultrasound,ct scan,Laproscope and modern robotic Surgery with the facility of FNAC, TRUCUT BIOPSY,FROZEN BIOPSY and better detectection and control of micro metastases has made much advancement leading to almost curbing and controlling Cancer denovo.

In Medical Biology Cancer is defined "Uncontrolled Growth of Cells." that is if our finger which is shaped like a finger is constituted by Bone,Many MUscles,Tendon,Nerve and Blood and Lymphatic vessels covered by skin with hairs,sweat glnd and many type of receptors of pain,temperature,touch etc, type of tissues and each of these tissues are made up of many cells,like a brick which forms our house.if one or few cells starts dividing rapidly and excess cells are not destroyed ,first the shape of Finger will be destroyed and then whole finger will be deformed and gradually such growth will spread to hand and will deform and dysfunction it too.Normally in our body there is a check and balance of every Growth,excess and unrequired growth is destroyed or designed sothat a proper shape and function of every organ is established.But once this check and balance is destroyed such growth is called "CANCER" or "TUMOR" which may be localised to the organ where it was orginated or spread to adjoining organs or may spred by Lymph or Blood vessels to differnet distanorgan as cancer of leg spreading to Brain,Liver,Lung etc. and vice versa.if locally organised Tumor these are called "BENIGN CANCER OR GOOD TUMORS' as once excised they are mostly completely curable with use of Surgery or radiotherapy BUT THOSE TUMORS WHICH SPREAD FROM ORIGINATIONG ORGAN TO OTHER ORGANS ARE CALLED "metastatic tumors or bad tumors or growth" as they are once removed from a local place by radio or Surery may recur immediately or after months or years from distant place ,so they are taken care of by using Chemotherapy or Cancer Drugs which also kills normal cell too,so are some time very toxic killing Blood,Hairs,skin and many growing cells bringing so many side effects,some time so much that we have to stop these medicines as patient cannot bear them physically and economically resulting into icreased morbidity and mortality.Newer added Medicines like Interferons,Monoclonal Antibodies,Genetherapy,Stem cells and modern cancer drugs are very very costly being out of reach from many Patients of Developing countries.

Human body is made up of 60 trillion cells and different type of Tissues which after combinig form differnt organs and Organs form the Body .Till date if these Organs are working synchronically or working in order from each organ to another organ ,Life exists as their chronological or systemic or disciplined working toghther is hampered or this cycle is stopped by any meber organ of cycle ,all organs stars failig one after another and we say Death occured,we donot know which is starting point and which is end point,some say Brain,Some Say Heart but in real sense it is their working togher with each other mattrers,no one is superior,no one is inferior. Most of the cells except the cells in the brain re-live by the process of division and replacement. It can be simply understood that after a given time the old cell is replaced by new cell, exact replica of its predecessor. The renewal of the cells after a given time is a natural process but uncontrolled growth of cells is not natural.Even some cells grow abnormally ,to start with these are killed by Body Immunity as checking mechanism but if growth is excessive or Immunity is not reacting ,these became permanent and called Cancer.This is the reason that cancer is not recognised as an abnormal activity by the immune system of the body and therefore, cancer detection is very difficult unless it affects the performance of an organ or organs,symptoms or signs are attributed to the organ concerned if Eye means loss of vission,if Larynx means loss of voice etc.,but Cancer in itself does not have any symptoms. The first question which comes to anyone's mind is –If it is not a natural process then why does a cell start uncontrolled growth? The exact answer for this question is not yet known to humanity. The answer to this question lies in identifying the part of the cell, which is responsible for initiating the process of self replication and excessive reproduction. Presumably, it may be some section in the DNA, cell membrane or may be anything else either being stimulated by some external things like sunlight in cancer of skin Melanoma or heat,or application of some chemicals used locally or ingested inside but many times cause is not exactly known,some cancer runs in family and strong genetic basis is present for every Cancer either coming as sporidally mutation of gene in an Individual or by hereditary in family.Here lies the success of stem therapy or gene Modulation or therapy to treat cancer.

Surgery is the basic of treating most cancers of Abdominal organs,Hand,leg or extremities,lung,brain,breast and chest wall ,skin etc but surgery completely cannot remove the whole tumor as tumor might have spread to important organ completely as to Liver or pancreas ,we cannot completely remove these organs so after a good chunk removal we use radiotherapy to remove these cells or we can use radiotherapy initially to control thest tumors and then can resect them once their size is less or can use with surgery or after it to rmove any remaining tumor unvisiblt that time or because of important organ not removed in first chance.Some time for mouth ,tongue,cervix,breast cancer we use Raditherapy to burn these tumor in first instance and donot use surgery at all but may use surgey if tumor remains after 8-10 wks of radiotherapy or if tumor recurs at this site .Similiarly for cancer of Blood and connective tissue crmotherapy or Medicines are only needed no sugery or Raditherapy is needed,some time to make tumor resectable we use cheotherapy first but mostly we use it after surgery or radiotherapy to remove tumor completely from originationg sit and then removing any micro spread which occured to ant distant organ either dtectable or undeteable in first phase or recurrence phase.

Overall the subject is very vast and many reasearches are going on making Human life more safe and precious ,the days will come soon when Man will win over this demon completely and even today our victory should not be ubderestimated because we can completely overcome Cancer if it is detected and treated in early stage by present modern gadgets of Surgery,Chemotherapy and radiotherapy,many Ayush and otherwise natural healers and therapist claim many medicnes to cure them completely by showing or claiming their personal cases and experiences,in this regard this is advisable that please expose first your claim internationally by publishing papers in good modern Journals of modern Medicines or of your subject or therapy,simple assertions and personal claim may not be hold good for many other patients as aberrations are known in medical science so,please refer the patient to good medicl college or centre when you see any cancer patient,donot keep patient in your clutch only,allow them to get detected the Disease or cancer completely and then get started the therapy ,with this therapy you may add your medicines too if you are very confident or qualified otherwise for earning money if some false promises or trials are done on some patients of villages or slum or from poor uneducated class of our country by so many self claimed healers or doctors using any therapy is a heinous crime on the earth and please restrain from this and help the society to curb this fatal disease completely and in first instance.

Dr.d.r.Nakipuria

Ambika chikitshalya

29 agrasen road

siliguri-734005


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Aug19
STRESS AND LISTENING TO GURU
STRESS
AND
LISTENING
TO
GURU


DR.
SHRINIWAS
KASHALIKAR
When we are in unbearable stress and nothing appears to provide solace, when life appears to have gone in vein; and when past, present and future appear to be null and void; we tend to start “sinking”! Our life begins to appear to be a tragic story of deception and defeat! We seem to be total losers, diffident, helpless and desperate for help.

Everything including what goes on; in our body, mind and in the world appears to be dissociated from us. There is total isolation. This condition; when nothing and nobody appear to provide any vitality when urgently needed; is a condition of gasping for life! Experience f such a condition is shattering, uprooting and devastating!

In such a dark and hopeless state of void; we “hear” a loving call enthralling our existence; from our innate core!

“Come on! My dear, I am always waiting for you within you; through millennia! But you were vagrantly getting oblivious to me from time to time for one reason or another! Let your subjective realm be culminated in me; because I am your true self! ”

This call fills one’s existence inside and out. It instantly connects us with everything hitherto “lost”! It transforms us from isolated drop to the entire ocean. It is enlivening and recharging every molecule of body and in fact the whole being! It is distinct and unforgettable! It is haunting from within and without!

Practice of NAMASMARAN initiates such call of guru; and in turn; such call of guru reinforces NAMASMARAN. We get reinstated from time to time within our true self and get empowered to proceed with NAMASMARAN in a more buoyant and pleasant manner; simultaneously helping ourselves and the millions to rejuvenate and blossom!


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